Monitoring pulmonary pressures during long-term continuous-flow left ventricular assist device and fixed pulmonary hypertension: redefining alleged pathophysiological mechanisms?

Pulmonary hypertension (PH) type II (classified by the World Health Organization) is a common complication in chronic left-sided heart failure. In advanced heart failure therapy, fixed PH is an absolute contraindication for heart transplantation after which a left ventricular assist device (LVAD) is the only remaining option. With remote monitoring, we can now continuously evaluate the pulmonary artery pressures during long-term LV unloading by the LVAD. In this case, we demonstrate that fixed PH can be reversed with LVAD implantation, whereby previous thoughts of this concept should be redefined in the era of assist devices

Haemolysis as a first sign of thromboembolic event and acute pump thrombosis in patients with the continuous-flow

Background Despite advances in pump technology, thromboembolic events/acute pump thrombosis remain potentially life-threatening complications in patients with continuous-flow left ventricular assist devices (CF-LVAD). We sought to determine early signs of thromboembolic event/ pump thrombosis in patients with CF-LVAD, which could lead to earlier intervention. Methods We analysed all HeartMate II recipients (n = 40) in our centre between December 2006 and July 2013. Thromboembolic event/pump thrombosis was defined as a transient ischaemic attack (TIA), ischaemic cerebrovascular accident (CVA), or pump thrombosis. Results During median LVAD support of 336 days [IQR: 182–808], 8 (20%) patients developed a thromboembolic event/pump thrombosis (six TIA/CVA, two pump thromboses). At the time of the thromboembolic event/pump thrombosis, significantly higher pump power was seen compared with the no-thrombosis group (8.2 ± 3.0 vs. 6.4 ± 1.4 W, p = 0.02), as well as a trend towards a lower pulse index (4.1 ± 1.5 vs. 5.0 ± 1.0, p = 0.05) and a trend towards higher pump flow (5.7 ± 1.0 vs. 4.9 ± 1.9 L m, p = 0.06). The thrombosis group had a more than fourfold higher lactate dehydrogenase (LDH) median 1548 [IQR: 754– 2379] vs. 363 [IQR: 325–443] U/L, p = 0.0001). Bacterial (n = 4) or viral (n = 1) infection was present in 5 out of 8 patients. LDH > 735 U/L predicted thromboembolic events/ pump thrombosis with a positive predictive value of 88%. Conclusions In patients with a CF-LVAD (HeartMate II), thromboembolic events and/or pump thrombosis are associated with symptoms and signs of acute haemolysis as manifested by a high LDH, elevated pump power and decreased pulse index, especially in the context of an infection

Mechanical Support in Early Cardiogenic Shock: What Is the Role of Intra-aortic Balloon Counterpulsation?

Purpose of Review: We aim to summarize recent insights and provide an up-to-date overview on the role of intra-aortic balloon pump (IABP) counterpulsation in cardiogenic shock (CS). Recent Findings: In the largest randomized controlled trial (RCT) of patients with CS after acute myocardial infarction

Mycobacterium chelonae, an ‘atypical’ cause of an LVAD driveline infection

We describe the first patient with a left ventricular assist device (LVAD) driveline infection caused by Mycobacterium chelonae presenting with persistent infection despite conventional antibiotics. Treatment was successful with surgical debridement, driveline exit relocation, and a 4-month period of antibiotics. In the case of a culture-negative LVAD driveline infection, non-tuberculous mycobacteria should be considered. This case illustrates tha

Homes in Flux : Multiple Layers of Domesticity among Syrian Refugees in Istanbul

To date, Turkey has one of the highest refugee populations in the world. The Syrian conflict has played a major role in this as over 2,5 million Syrians have taken refuge in Turkey. Most of Syrian refugees are residing in the largest city of Turkey, Istanbul. Turkey is a signatory member of the Convention relating to the Status of Refugees, however has an exception for permanent residency granted only for European refugees. Thus, under Turkish refugee policy, Syrians are merely granted temporary protection that guarantees them a temporary residency permit. However, the policy does not cover; at the time of this research; the right to work. Syrian refugees, undocumented Syrians and Syrian Palestinians are especially vulnerable in Turkish society due to the lack of permanent residency and legal work. This research identifies how Syrian refugees create home as well as the factors that influence their home-making process in Istanbul. The factors are evaluated through the conditions under which Syrian refugees are residing in Istanbul including the right to work, housing and residency. The research also evaluates the refugees home-making in retrospective to their living conditions, feeling of home, legal position, access to a dwelling place as well as cultural identification. Although, this research focuses on the individual experience of home-making for Syrian refugees, it considers and examines Syrian refugees in a context of politicised bodies. As international refugees, Syrian refugees are highly politicized bodies, whose lives are affected by international politics as well as the domopolitics of the country in which they reside. Subsequently, their home and their home-making processes are also politicised. Beyond politics, refugeeness alters one's relationship to home and place, making home a complex concept attached with emotions and potential pain and loss. Literacy identifies that refugees displace their home through space and time. Hence, this research treats home as a socially and culturally produced metaphor that describes a person's belonging within socio-spatial narratives, but of which content is individually chosen to describe or to support a person's identity and psychological environment. The method of this research was a combination of two field trips to Istanbul, Turkey, fourteen in-depth interviews and qualitative analysis. The main reference of the research are the fourteen in-depth interviews that included ten men and four women; aged from 20 to 40 years old; Syrians residing in Istanbul. The interviewees were selected through social media online connections and face-to-face acquaintances during the field trips. The interviewees time of residence in Istanbul varied from two months to over four years. The eleven influencing factors identified in this research can be more commonly divided into two categories: the common factors and the personal factors. Common factors related to the responder's habitation environment; such as the city of Istanbul and the Turkish society. These common factors included: the city itself, the Turkish culture and society, the legislation, working life, housing, discrimination and relationships with their family and friends as well as with the Turkish people. The interviewees considered these factors as the ones that impacted everyday life and which they could not 'escape'. Personal factors that were identified are related to interviewees personality, world views and emotions. The interviewees could be divided into four main categories of personal factor denominators: their relationship to Syria, sense of belonging, definition of home and views of the future. This research concludes that displacement has an impact on how home is perceived and reflected by the interviewees. Its findings are in accordance to previous research literature on home-making among refugees, but it questions refugee policies that emphasis on repatriation as the most favourable long term solution for refugees as well as the position of housing as a most influential factor in refugees' home-making, by stating that other factors such as relationship to family and friends and earning a living, are higher in importance for those who have arrived into a new country less than two years ago.Syyrian kriisin myötä Turkissa asuu tänä päivänä maailman laajin pakolaisyhteisö: 2,5 miljoonaa. Suuri osa Syyrian pakolaisista on asettunut asumaan Turkin suurimpaan kaupunkiin, Istanbuliin. Syyrian pakolaisilla on Turkissa erikoisasema: heitä varten on säädetty erikseen pakolaisasetus, joka määrittelee syyrialaisten pakolaisten aseman Turkissa. Syyrialaiset saavat oleskella maassa niin kutsutun väliaikaisen suojeluksen nojalla, joka estää suojelusta hakevien palautukset Syyriaan, mutta tutkimuksen aikaan ei tarjonnut mahdollisuutta työskennellä laillisesti tai pysyvää oleskelulupaa. Tämä asetus laittaa syyrialaiset pakolaiset hyvin haavoittuvaan asemaan turkkilaisessa yhteiskunnassa, jossa suurin osa työskentelee laittomasti ja heillä on ongelmia muun muassa hankkia asuntoa. Tämä tutkimus perehtyy siihen, kuinka syyrialaiset pakolaiset tekevät kodin Istanbulissa ja mitkä tekijät vaikuttavat kodin tekemiseen. Näitä tekijöitä tarkastellaan niiden olosuhteiden kautta, jotka syyrialaisilla vallitsevat Istanbulissa. Huomioon otettuja seikkoja ovat muun muassa laillinen asema, asema asuntomarkkinoilla, työskentelymahdollisuudet, kulttuurinen identifioituminen sekä kodin kokeminen. Vaikka tämä tutkimus keskittyy yksilöllisiin kokemuksiin, syyrialaisten pakolaisten kodin tekemistä tarkastellaan myös pakolaiskontekstissa, jossa pakolaisten kodin tekeminen on politisoitunutta. Pakolaisina syyrialaiset ovat hyvin politisoituja henkilöitä, joiden kodin tekemiseen vaikuttaa isäntämaan domopolitiikka kuten myös kansainvälinen politiikka. Poliittisen näkökulman lisäksi tutkimus nojaa kirjallisuuteen pakolaisten kodin tekemisestä, joka huomioi pakolaisuuden muuttavan yksilön suhdetta ja käsitystä kodista. Kodin nähdään olevan merkityksellinen konsepti juuri siihen kohdistuvan menetyksen ja kivun vuoksi. Tutkimuksessa käytetyssä kirjallisuudessa pakolaisten nähdään sijoittavan kodin useisiin eri paikkoihin ja myös aikoihin. Tämä tutkimus käsittelee kotia sosiaalisesti ja kulttuurisesti tuotettuna metaforana, joka kuvaa henkilön kuulumista sosio-spatiaalisissa narratiiveissa, mutta jonka sisällön yksilö valitsee kuvatakseen tai tukeakseen omaa identiteettiään ja psykologista hyvinvointiaan. Tutkimuksen metodina on kvalitatiivinen analyysi. Sen aineisto on kerätty neljästätoista syvähaastattelusta ja kahdesta tutkimusmatkasta Istanbuliin. Haastateltavat olivat 20-40-vuotiaita syyrilaisia, jotka olivat eläneet Istanbulissa kahdesta kuukaudesta yli neljään vuoteen. Haastateltavat valittiin sosiaalisen median välityksellä luotujen suhteiden kautta. Tutkimuksessa selvisi yksitoista kodin tekemiseen vaikuttavaa tekijää, jotka on jaettu yleisiin ja yksilöllisiin tekijöihin. Yleiset tekijät ovat elinympäristöstä nousevia tekijöitä, jotka vaikuttivat kaikkiin haastateltaviin. Nämä tekijät olivat Istanbul kaupunkina, turkkilainen kulttuuri ja yhteiskunta, lainsäädäntö, työelämä, syrjiminen, ihmissuhteet perheeseen, ystäviin ja turkkilaisiin. Yksilölliset tekijät ovat haastateltavan persoonasta, maailmankatsomuksesta ja tunteista nousevia tekijöitä, jotka yleisten tekijöiden lailla vaikuttivat haastateltavien kodin kokemukseen. Yksilölliset tekijät jakautuivat neljään kategoriaan: haastateltavien suhteeseen Syyriaan, kuulumisen kokemukseen, kodin merkitykseen ja tulevaisuuden näkemyksiin. Tämän tutkimuksen tulokset tukevat aikaisempaa tutkimusta pakolaisten kodin tekemisestä ja siitä, kuinka kotimaassa sijainneen kodin menetys vaikuttaa siihen, kuinka pakolaiset käsittävät ja kokevat kodin. Tutkimus kuitenkin kyseenalaistaa pakolaisten kotouttamiseen liittyviä poliittisia ratkaisuja, kuten kotimaahan palauttamisen ensisijaisena vaihtoehtona. Tutkimuksessa kävi myös ilmi, että asumuksen sijaan kotoutumisen kannalta ensisijaisia tekijöitä olivat suhteet perheeseen ja ystäviin ja elannon ansaitseminen alle kaksi vuotta Istanbulissa asuneiden haastateltavien keskuudessa

First-Line Support by Intra-Aortic Balloon Pump in Non-Ischaemic Cardiogenic Shock in the Era of Modern Ventricular Assist Devices

Objectives: Little is known about circulatory support in cardiogenic shock (CS) from other causes than the acute coronary syndrome or after cardiotomy. We evaluated the effects of first-line intra-aortic balloon pump (IABP) support in this subpopulation of CS patients. Methods: A retrospective study was performed in 27 patients with CS from end-stage cardiomyopathy supported firstly by IABP in the years 2011-2016. Results: At 24 h, lactate decreased from 3.2 (2.1-6.8) to 1.8 (1.2-2.2) mmol/L (p < 0.001). Eighteen patients (67%) defined as IABP responders were successfully bridged to either recovery (n = 7), left ventricular assist device (n = 5), or heart transplantation (n = 6). IABP failed in 9 patients (non-responders, 33%) who either died (n = 7) or needed support by extracorporeal membrane oxygenation (n = 2). At 24 h of IABP support, urinary output was higher (2,660 [1,835-4,440] vs. 1,200 [649-2,385] mL; p = 0.02) and fluid balance more negative (-1,564 [-2,673 to -1,086] vs. -500 [-930 to +240] mL; p < 0.001) in responders than non-responders. Overall survival at 1 year was 63%. Conclusion: In most patients, first-line support by IABP in end-stage cardiomyopathy is associated with improvement in organ perfusion and clinical stabilisation for at least 24 h allowing time for decision making on next therapies

Incidence of end-stage renal disease after heart transplantation and effect of its treatment on survival

Aims: Many heart transplant recipients will develop end-stage renal disease in the post-operative course. The aim of this study was to identify the long-term incidence of end-stage renal disease, determine its risk factors, and investigate what subsequent therapy was associated with the best survival. Methods and results: A retrospective, single-centre study was performed in all adult heart transplant patients from 1984 to 2016. Risk factors for end-stage renal disease were analysed by means of multivariable regression analysis and survival by means of Kaplan–Meier. Of 685 heart transplant recipients, 71 were excluded: 64 were under 18 years of age and seven were re-transplantations. During a median follow-up of 8.6 years, 121 (19.7%) patients developed end-stage renal disease: 22 received conservative therapy, 80 were treated with dialysis (46 haemodialysis and 34 peritoneal dialysis), and 19 received a kidney transplant. Development of end-stage renal disease (examined as a time-dependent variable) inferred a hazard ratio of 6.45 (95% confidence interval 4.87–8.54, P < 0.001) for mortality. Tacrolimus-based therapy decreased, and acute kidney injury requiring renal replacement therapy increased the risk for end-stage renal disease development (hazard ratio 0.40, 95% confidence interval 0.26–0.62, P < 0.001, and hazard ratio 4.18, 95% confidence interval 2.30–7.59, P < 0.001, respectively). Kidney transplantation was associated with the best median survival compared with dialysis or conservative therapy: 6.4 vs. 2.2 vs. 0.3 years (P < 0.0001), respectively, after end-stage renal disease development. Conclusions: End-stage renal disease is a frequent complication after heart transplant and is associated with poor survival. Kidney transplantation resulted in the longest survival of patients with end-stage renal disease